Save Print Reset

STATE OF MISSOURI THIS ORIGINAL FORM MUST BE FILLED OUT IN DUPLICATE AND MAILED TO:
DEPARTMENT OF CORRECTIONS DEPARTMENT OF CORRECTIONS

APPLICATION FOR EXECUTIVE CLEMENCY

MISSOURI BOARD OF PROBATION AND PAROLE
P.O. BOX 236
JEFFERSON CITY, MO 65102

1. APPLICANT NAME TELEPHONE NUMBER

ADDRESS CITY STATE ZIP

2. TYPE OF CLEMENCY REQUESTED (CHECK ONLY ONE) PARDON COMMUTATION OF SENTENCE RESTORATION OF CIVIL RIGHTS
3. WHAT IS YOUR REASON FOR MAKING APPLICATION AT THIS TIME?

4. IS PARDON SOUGHT TO GAIN ELIGIBILITY FOR A PERMIT, LICENSE, OR TO PRACTICE IN A SPECIFIC EMPLOYMENT AREA?

YES NO (IF YES, PLEASE EXPLAIN)

5. DATE OF BIRTH SOCIAL SECURITY NUMBER 6. GIVE NAME YOU USED AT THE TIME OF CONVICTION (IF DIFFERENT FROM ABOVE)

7. ARE YOU CURRENTLY CONFINED IN A CORRECTIONAL FACILITY? 8. HAVE YOU EVER HAD A PROBATION, PAROLE OR CONDITIONAL RELEASE REVOKED?

YES NO YES NO
9. CONVICTION(S) FOR WHICH YOU ARE REQUESTING CLEMENCY:
DATE CHARGE COUNTY SENTENCE

A.

B.
C.
10. PRIOR CONVICTIONS (CONVICTIONS OTHER THAN LISTED ABOVE):
DATE CHARGE COUNTY DISPOSITION

A.

B.

C.
11. HAVE YOU PREVIOUSLY APPLIED FOR EXECUTIVE CLEMENCY? YES NO

DISPOSITION? DATE
APPLICANTS WHO ARE CURRENTLY CONFINED IN A CORRECTIONAL FACILITY, SKIP TO # 15
12. WHERE HAVE YOU LIVED DURING THE PAST FIVE YEARS, AND WITH WHOM? (COMPLETE NAME AND ADDRESS)

13. WHAT IS YOUR OCCUPATION?

14. LIST EACH JOB YOU HAVE HELD FOR THE PAST FIVE YEARS, GIVING THE FOLLOWING INFORMATION
NAME OF EMPLOYER ADDRESS DATE EMPLOYED REASON LEFT

15. GIVE REFERENCES (INDIVIDUALS WHO HAVE KNOWN YOU FOR AT LEAST FIVE YEARS)
NAME ADDRESS TELEPHONE NUMBER

NAME ADDRESS TELEPHONE NUMBER

APPLICANTʼS SIGNATURE DATE

THIS APPLICATION IS SUBJECT TO INVESTIGATION, THEREFORE, ANY WILLFUL MISREPRESENTATION OR DELETION ARE GROUNDS FOR REJECTION. AUTHORITY
TO GRANT EXECUTIVE CLEMENCY IS PURSUANT TO ARTICLE IV, SECTION 7 OF THE CONSTITUTION OF MISSOURI.

MO 931-1883 (2-10)